Custom Sandal and Clog Program 2016 United States: 2905 Veterans Memorial Highway, Suite #2, Ronkonkoma, NY, 11779 T: 800-645-5520 | F: 800-419-0772 Canada: 160 Markland Street, Markham, Ontario, Canada, L6C-OC6 T: 877-644-4344 | F: 866-538-9472

Please: Serial #______• Submit one form for each pair ordered. Opened By______Incoming Postage______• Call ahead with any special instructions. Date Received______• Avoid processing delays by providing ALL requested information. LAB USE ONLY • Order carefully. Additions and accommodations requested after Patient Information the initial order is placed will incur a fee. Patient’s First Name ______Practitioner/Clinic Information Patient’s Last Name______Account #______P.O.______Street Address______Account Name______City/St/Zip/Postal Code______Practitioner Name______Telephone ( )______Date of Birth (M/D/Y)______Phone______Fax______Diagnosis or Chief Complaint______Email______(not intended for severely compensated feet) Street Address______City/St/Prov______REQUIRED INFORMATION Zip/Postal Code______Sex  M  F Height ______Weight ______ Recast from previous order  Return cast to clinician Shoe Size______WIDTH (very important)______Serial #______ Weight bearing tracing enclosed  Custom copy authorization Charge to:  MasterCard  VISA  Amex  Discover  This is a prepaid order #______ Check enclosed Check #______Expiration Date______Signature______ Money order enclosed Check #______

ADDITIONS AND MODIFICATIONS Naot® Right Left Women’s Aster Women’s Melody Heel Cushion    Black Matte Leather  Buffalo Leather  Metallic Road Leather  Stardust Leather    Met Pad   Vintage Gray Leather Gold Shimmer Leather Silver Thread Leather Pressure Disbursement Pad   Women’s Anika Women’s Mikaela  Brushed Black Leather  Shiraz Leather  Crazy Horse Leather Full Sole Varus Wedge    Silver Threads Leather  Biscuit Leather Full Sole Valgus Wedge   Women’s Jive  Beige Snake Leather  Shiny Black Leather Heel Spur Pad   Women’s Rome Men’s Jeff Heel Raise     Black Matte Leather Buffalo Leather     Oily Brown Nubuck 1/8” 3/16” 1/4”  Rumba Leather  Polar sea Leather Toe Crest   Men’s Fiord Women’s Karaoke  Black Leather  Crazy Horse Leather Special Topcover    White Leather  Metal Leather  Neoprene  Plastazote®  PPT®  Black Leather  Stardust Leather Men’s Lappland (Standard 1/8”)  Black Matte Leather  Buffalo Leather Women’s Sound  Vintage Gray Leather Comments/Special Instructions  Gold Grecian Leather  Men’s Mikael ______Black Madras Leather  Crazy Horse Leather  Vintage Gray Leather ______Women’s Karenna ______ Black Crinkle Leather  Buffalo Leather ______ White Leather  Black Luser leather ______ Stardust Leather  Black Matte Leather  ______Luggage Brown Leather ______